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Please fill in the information below. You will need the age of the roof.
Your Legal Name (MUST INCLUDE MIDDLE INITIAL)
*
First Name
Middle Initial
Last Name
Date Of Birth
*
/
Month
/
Day
Year
Social Security #
This is a soft hit to obtain your credit history, not your credit score, therefore it will not lower your credit score or have any impact on your loan
Driver's License Number (Some Of Our Companies Require a Driver's License Number Even For A Home Insurance Quote)
State
Number
Spouse's legal name, or name of second person listed on the loan or deed. Your spouse is required to be listed on the insurance even if they are not on the loan. Enter NONE if no one else (MUST INCLUDE MIDDLE INITIAL)
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First Name
Middle Initial
Last Name
Date of Birth for spouse/second person. Enter NONE if no one else
*
Social Security # for spouse/second person. Enter NONE if no one else
This is a soft hit to obtain your credit history, not your credit score, therefore it will not lower your credit score or have any impact on your loan
Driver's License Number (Some Of Our Companies Require a Driver's License Number Even For A Home Insurance Quote)
State
Number
Have you, or the co-borrower, filed for bankruptcy?
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No
Yes (Enter The Year You Filed Below)
Address of the house you need a quote for
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your current address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Type of house
*
Primary Single Family Home (You will be living there full time)
Seasonal/Secondary Single Family Home (You will live there part time)
Long Term Rental (Someone other than you will be living in the home with an annual or semi-annual contract)
Short Term Rental (Airbnb or VRBO)
Vacant (Already own, will be vacant until it sells)
Flip House/Investment (Buying to remodel, then sell)
Mobile/Manufactured Home
Date you want the policy to start (the closing date if this is a new purchase)
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-
Month
-
Day
Year
Date
Approximate date you will move into the house. Use todays date if you already live there
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-
Month
-
Day
Year
Date
Year house was built
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Foundation type
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Crawlspace
Walkout Basement (Door in the basement to the outside)
Inground Basement (No outside door)
Slab
Percentage of basement that is finished
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No Basement
25%
50%
75%
100%
Unfinished Basement
How many square feet is the house
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How many stories is the house (NOT INCLUDING A BASEMENT)
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1
1.5
2
2.5
Attached garage spaces
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1
2
3
4
None
Year roof was replaced. This is a big factor in the price, so If you are unsure you will need to ask the realtor or seller
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Outside material of the house such as brick, vinyl siding, asbestos etc. If more than one list all of them. Example: front brick, 3 sides vinyl siding
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How many acres is the property?
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Are there any sheds or barns on the property? If so, please describe number and dimensions if possible
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Number of FULL bathrooms
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1
2
3
4
5
Number of HALF bathrooms
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None
1
2
3
4
Will you operate any type of business or daycare out of the house? If yes, please describe
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Will you have any dogs or livestock on the property? (IF YES, HOW MANY AND WHAT BREED/KIND)
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Supplemental Heat
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Gas Fireplace
Wood Fireplace
Wood Insert
Free Standing Wood Stove
Free Standing Pellet Stove
Outdoor Wood Stove
None of the above
Will there be a swimming pool
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No
Above Ground
In Ground
Will there be a trampoline. (Net and padded springs are required)
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No
Yes
Is the back yard fenced
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No
Yes
Electrical
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Breakers
Fuses
Water Supply
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City Water
Private Well
Shared Well
Does the home have solar panels?
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No
Yes (Enter the value and location (roof or yard) below)
Do you want water backup coverage? It provides coverage if the sump pump in the basement fails and causes water damage, or the sewer/septic backs up into the house and causes water damage. Average cost is $50-$100/year for $10,000 in coverage
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No
Yes
Do you want to add service line coverage? This provides coverage if the buried utility lines in your yard need to be replaced or repaired. The average cost is $40/year for $10,000 in coverage.
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No
Yes
Who will pay the home insurance?
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The mortgage company(Insurance is escrowed)
I will pay in full
I will pay monthly
Sales price of the home, or current coverage amount if you already own it.
Would you be interested in an auto insurance quote? You may receive a bundle discount on the home insurance. If you select Yes, please CLICK THE LINK ONCE YOU HIT SUBMIT TO ENTER THE AUTO INSURANCE INFORMATION.
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Yes
No
Who is your current auto insurance company?
How did you hear about us? Person(First & Last Name), Google, Facebook
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Submit
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